A prospective neurosurgical registry evaluating the clinical care of traumatic brain injury patients presenting to Mulago National Referral Hospital in Uganda.

Benjamin J Kuo,Gerald A Grant,Joel Kiryabwire,Joao Ricardo Nickenig Vissoci,Hussein Ssenyonjo,Michael M Haglund,Linda Xu,John Mukasa,Lydia Nanjula,Silvia D Vaca,Henry E Rice,Michael Muhumuza,Catherine A Staton,Christine Muhumuza,Mojgan Hodaie

doi:10.1371/journal.pone.0182285

Abstract

BackgroundTraumatic Brain Injury (TBI) is disproportionally concentrated in low- and middle-income countries (LMICs), with the odds of dying from TBI in Uganda more than 4 times higher than in high income countries (HICs). The objectives of this study are to describe the processes of care and determine risk factors predictive of poor outcomes for TBI patients presenting to Mulago National Referral Hospital (MNRH), Kampala, Uganda.MethodsWe used a prospective neurosurgical registry based on Research Electronic Data Capture (REDCap) to systematically collect variables spanning 8 categories. Univariate and multivariate analysis were conducted to determine significant predictors of mortality.Results563 TBI patients were enrolled from 1 June– 30 November 2016. 102 patients (18%) received surgery, 29 patients (5.1%) intended for surgery failed to receive it, and 251 patients (45%) received non-operative management. Overall mortality was 9.6%, which ranged from 4.7% for mild and moderate TBI to 55% for severe TBI patients with GCS 3–5. Within each TBI severity category, mortality differed by management pathway. Variables predictive of mortality were TBI severity, more than one intracranial bleed, failure to receive surgery, high dependency unit admission, ventilator support outside of surgery, and hospital arrival delayed by more than 4 hours.ConclusionsThe overall mortality rate of 9.6% in Uganda for TBI is high, and likely underestimates the true TBI mortality. Furthermore, the wide-ranging mortality (3–82%), high ICU fatality, and negative impact of care delays suggest shortcomings with the current triaging practices. Lack of surgical intervention when needed was highly predictive of mortality in TBI patients. Further research into the determinants of surgical interventions, quality of step-up care, and prolonged care delays are needed to better understand the complex interplay of variables that affect patient outcome. These insights guide the development of future interventions and resource allocation to improve patient outcomes.

Highlights

Annual global death from injury is estimated to be 5 million, of which 90% occur in low- and middle-income countries (LMICs).[1,2] Rising injury mortality can be attributed in part to the 50% increase in road traffic injuries (RTI) over the past two decades, accounting for a quarter of deaths from injury.[1]
The objectives of this study are to describe the processes of care and determine risk factors predictive of poor outcomes for traumatic brain injury (TBI) patients presenting to Mulago National Referral Hospital (MNRH), Kampala, Uganda
563 TBI patients were enrolled from 1 June– 30 November 2016. 102 patients (18%) received surgery, 29 patients (5.1%) intended for surgery failed to receive it, and 251 patients (45%) received non-operative management

Summary

Introduction

Annual global death from injury is estimated to be 5 million, of which 90% occur in low- and middle-income countries (LMICs).[1,2] Rising injury mortality can be attributed in part to the 50% increase in road traffic injuries (RTI) over the past two decades, accounting for a quarter of deaths from injury.[1]. The global incidence of TBI from RTIs is disproportionately concentrated in LMICs with rates of 150–170 per 100,000 TBI in Sub Saharan Africa (SSA) compared to 106 per 100,000 globally.[6] this burden is compounded by greater risk factors and limited healthcare capacity in LMICs.[5] In a study comparing mortality from injury between Kampala Uganda and the United States, 25% of all deaths in Kampala were due to injuries compared to 7% in the United States, and the odds of dying from injury were 4.2 times higher in Uganda.[7]. Traumatic Brain Injury (TBI) is disproportionally concentrated in low- and middle-income countries (LMICs), with the odds of dying from TBI in Uganda more than 4 times higher than in high income countries (HICs). The objectives of this study are to describe the processes of care and determine risk factors predictive of poor outcomes for TBI patients presenting to Mulago National Referral Hospital (MNRH), Kampala, Uganda

Objectives

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Discussion

Conclusion